The American Occupational Therapy Association
Advisory Opinion for the Ethics Commission
Establishing Professional Boundaries: Where to Draw the Line
The basic tenets of the altruistic occupational therapy profession are helping others and doing no
harm. Individuals have the desire to develop relationships for companionship, socialization, and
intimacy. However, when one is in a therapeutic (or professional) rather than personal relationship,
professional boundaries must guide conduct and decision making in the clinical or educational
setting and beyond. Practitioners and educators can find guidance in organizational and
university policies; county human re-sources manuals (for school system employees); state, federal,
and international laws; and American Occupational Therapy Association (AOTA) Official
Documents, such as the Occupational Therapy Code of Ethics (2015) (referred to as the “Code”;
AOTA, 2015), when they are faced with uncertainty or ethical dilemmas regarding appropriate
professional boundaries in the workplace. Codes of ethics from other health professions can also
provide assistance. In addition, case studies in this Advisory Opinion provide examples of situations
in which one is faced with an ethical dilemma related to appropriate professional boundaries and
how the Code and other AOTA documents can guide the practitioner or educator in resolving
them.
DEFINING P R O F E S S I O N A L BOUNDARIES
Professional boundaries set limits and define parameters (Tetreault, 2010). There is a
continuum of professional behavior related to professional boundaries, ranging from helpful to
non-productive or inappropriate. An occupational therapy practitioner is in a helpful zone, for
example, when working with the client toward achieving his or her occupational therapy goals and
promoting a professional client– practitioner relationship. The helpful zone could also include the
relationship between faculty or educators in an occupational therapy program and the students they
instructor mentor, either in the classroom or on fieldwork. However, a professional may cross a
boundary to satisfy his or her own personal agenda or needs.
If a practitioner or educator crosses the line toward either underinvolvement or overinvolvement
along the continuum of conduct, then his or her actions could be considered unlawful or unethical.
Crossing boundaries unintentionally may still constitute unethical behavior. Underinvolvement
can occur when the practitioner neglects the needs of clients by becoming disengaged. Perhaps a
practitioner seems bored, is not attentive to client input or response, or ignores protocols and safety
measures. Practitioners need to be continually alert and focused on their work to deliver the quality
of care clients expect and deserve, consistent with Principle 1 (Beneficence) of the Code. Failure to
conduct oneself in this manner could also place a client in an unsafe situation.
Overinvolvement may occur in a clinical situation if a practitioner demonstrates behavior that is
outside the generally acceptable standards of professional conduct. For example, engaging in
personal conversation or requesting personal advice from a client may fall in this category. In
academia, faculty could be perceived as being underinvolved if they are not attentive to students’
issues and concerns related to their studies or fieldwork. They may be overinvolved with a student
when they engage in activities planned outside of school that may or may not be related to academics.
When a practitioner or educator’s actions do not follow the usual and customary standards of
professional conduct with a client or student, he or she could be in violation of organizational
policies, the Code, international or federal laws, or the state practice act (National Council of State
Boards of Nursing, 2014).
Principle 2 of the Code (AOTA, 2015) defines Nonmaleficence as grounded in the practitioner’s
responsibility to refrain from causing harm. Principles 2F, 2G, and 2I specifically delineate
conduct that practitioners should avoid to adhere to professional boundaries. Principle 2I clearly
states that one must “avoid exploiting any relationship established as an occupational therapy
clinician, educator, or researcher to further one’s own physical, emotional, financial, political, or
business interests at the expense of recipients of services, students, research participants, employees,
or colleagues” (AOTA, 2015, p. 4). Principle 2G states that one must “avoid engaging in any sexual
activity with a recipient of service (including the client’s family or significant other), student,
research participant, or employee while a professional relationship exists” (p. 3). Principle 2F states
that one must “avoid dual relationship, conflicts of interest, and situations in which a practitioner,
educator, student, researcher, or employer is unable to maintain clear professional boundaries or
objectivity” (p. 3).
When practitioners or educators are faced with ethical dilemmas and cannot find solutions
in their state practice acts, organizational policy manuals, or Association documents, they may
need to seek additional resources from supervisors and ethics committees or find support in the
ethics standards of other professions. For example, as occupational therapy practitioners and
students, we address psychosocial issues in our clients or patients and their families. Thus, the
American Psychological Association (APA) may provide occupational therapy practitioners with
additional insight into appropriate roles and boundaries. The APA addresses professional
boundaries with a construct it calls multiple relationships:
A multiple relationship occurs when a psychologist is in a professional
role with a person and (1) at the same time is in another role with the
same person, (2) at the same time is in a relationship with a person
closely associated with or related to the person with whom the psychologist
has the professional relationship, or (3) promises to enter into another
relationship in the future with the person or a person closely associated
with or related to the person. . . . A psychologist refrains from entering into
a multiple relationship if the multiple relationships could reasonably be
expected to impair the psychologist’s objectivity, competence, or
effectiveness in performing his or her functions as a psychologist, or
otherwise risks exploitation or harm to the person with whom the
professional relationship exists. (APA, 2010)
Thus, occupational therapy practitioners should be alert to circumstances in which they find
themselves in different roles with the same individual (e.g., friend and client, lover and family
member of client). In academia, educators must avoid engaging in relationships with students
that could lead to conflicts of interest as well as affect “professional judgment and objectivity”
(AOTA, 2011, p. 10). When two roles coincide, there is potential for conflicting allegiances and
a loss of the clinician or educator’s ability to maintain the best interests of the client or student at
the forefront.
In addition, because occupational therapy practitioners often share very intimate moments with
their clients, the language used in the Nursing Code of Ethics (American Nurses Association [ANA],
2015) may prove helpful with issues related to professional boundaries. The Nursing Code of
Ethics Section 2.4, Professional Boundaries, emphasizes that the primary focus of nursing must be
on the well-being of the patient and that professional boundaries must be maintained to achieve
that end.
CASE SCENARIOS
WHENA FAMILY MEMBER NEEDS OCCUPATIONAL THERAPY
Nancy works as an occupational therapist in a skilled nursing facility (SNF) to which her
uncle was admitted for rehab. Although she was both an employee of the SNF and a family
member of a client who resided there, she was not the occupational therapist who provided
treatment to her uncle. She could not find guidance from her state regulations that addressed
whether an occupational therapy practitioner could treat a family member, but she decided it
was best to avoid that role. Principle 2F of the Code, previously mentioned, supports her
decision not to treat her uncle, because it states that situations that interfere with objectivity
should be avoided. Principle 4 states that occupational therapy services should be provided with
fairness and objectivity. If Nancy had decided to be her uncle’s occupational therapist, others
might have perceived that she was providing special treatment to a family member. Nancy and
the family member needed to respect the decisions that were made by the rehabilitation team,
nursing staff, and facility policies throughout the uncle’s stay.
STUDENT–FACULTY RELATIONSHIPS
Susan is a professor of occupational therapy at the state university. When her daughter was
involved in Girl Scouts, Susan served as the assistant troop leader. Susan became close to
Marcie, the troop leader, who was then a stay- at-home mom.
Marcie learned about occupational therapy from Susan, and when her children got older, she
decided to pursue occupational therapy as a career. She was accepted to the occupational therapy
program at the state university where Susan teaches. Susan can imagine how difficult it must be
to return to school at the age of 40 and wants to help Marcie be successful in the program.
Although Susan’s concern for her friend is natural, she risks showing favoritism if she
helps Marcie more than other students. This would be considered nonmaleficence, because she
would be entering into a situation in which she might find it difficult “to maintain clear
professional boundaries or objectivity” (Principle 2F; AOTA, 2015, p. 3). In addition, she risks
violating Principle 5G (Veracity) if she finds herself grading her friend more leniently and is not
“honest, fair, accurate, respectful, and timely in the gathering and reporting fact- based
information regarding . . . student performance” (p. 6). Susan should disclose her prior relationship
with Marcie to the department chair and seek guidance as to how to proceed. Additionally, she
should give Marcie information about resources provided by the university to assist
nontraditional students in reaching their career goals.
GENERAL SOCIALIZING AND FRATERNIZING: ONLINE SOCIAL NETWORKING
Sam is an occupational therapist who works for a company that provides outpatient
occupational therapy services. One of Sam’s friends needed occupational therapy services and
decided to receive them at the clinic where Sam works. Sam thought it would be acceptable to
treat his friend, who is also a Facebook friend, as long as he kept everything transparent. Sam
was aware of professional boundaries and knew not to provide advice to his friend outside of the
clinic. He discussed this with his boss, and they decided that as long as Sam treated his friend in
the same way that he would treat any of his other clients (e.g., no preferential scheduling, billing
adjustments), then it should not be a problem.
During the course of treatment, Sam’s friend posted information about his experience with
therapy on his Facebook page. As stated in the AOTA Advisory Opinion on social networking,
those who “engage in online friendships with clients can jeopardize professional boundaries by
involvement in a dual relationship with service recipients” (AOTA, 2011, p. 2). It is best to avoid
this type of relationship, when possible, because of perceived conflict of interest and concerns
about privacy and confidentiality. Although it may not be unlawful to have a client who is a friend,
it may provoke ethical challenges and is not recommended.
DATING AND ROMANTIC RELATIONSHIPS
Rhonda is a 35-year-old occupational therapist who works with adults in an outpatient
setting. One of her clients is José, a 37-year-old man who was injured in a skydiving accident
that resulted in C6 incomplete quadriplegia.
Rhonda has been working with José for 1 month, and José has achieved dressing and
bathing independence as well as the ability to use the commode with minimal assistance. As
José’s self-esteem has improved, he has begun to flirt with Rhonda and eventually asks her out
on a date. Rhonda is unsure about what she should do, because she doesn’t want to hurt José’s
feelings and senses that he sees her as a “safe” first date to try out his new body image. Rhonda
has shared many intimate moments with José during the course of his rehabilitation. As such,
she would be entering into the relationship with far more information about José than she might
naturally have in a normal dating relationship.
This places Rhonda in a situation in which, according to Principle 2I of the Code, she could
potentially exploit the recipient of services physically, emotionally, or psychologically.
Additionally, should the possibility of a sexual relationship arise, Rhonda would find herself
breaching Principle 2G, which states that one must “avoid engaging in sexual activity with a
recipient of service (including the client’s family or significant other), student, research
participant, or employee while a professional relationship exists” (AOTA, 2015, p. 3).
The most appropriate response to José’s request for a date is to let him know that the
AOTA Code prohibits a relationship with him while he is a client. After his discharge from the
facility, Rhonda should seriously consider the appropriateness of entering into any type of
relationship with him, as the balance may be skewed because of their previous interactions as
client and therapist. In addition, individuals who have been through a traumatic health event are
vulnerable, and the professional burden is on the occupational therapy practitioner to set and
maintain clear boundaries for the therapeutic relationship to protect his or her client. Rhonda
should also consult her state occupational therapy practice act and facility regulations for
additional guidance.
SUPERVISOR AND STUDENT RELATIONSHIPS
Franklin is a Level II occupational therapy fieldwork student from New York City who is
assigned to a remote hospital in North Dakota. Franklin’s fieldwork supervisor, Don, is a recent
graduate who also came from a big city to this small town. Don senses Franklin’s loneliness, and
they become friends, enjoying beers after a long day and working out at the gym together. Don’s
intentions are good—he is trying to make a difficult situation better for his student. However, the
development of a friend relationship with a person he has to supervise and evaluate places him in an
awkward situation, and it challenges several ethical standards.
Principle 2D of the Code states that “occupational therapy personnel shall avoid any
undue influences that may impair practice and compromise the ability to safely and competently
provide occupational therapy services, education, or research” (AOTA, 2015, p. 3).
Additionally, there is a potential for exploiting the student, as discussed in Principle 2F,
because their relationship outside of work hours may conflict or interfere with Don’s professional
judgment and objectivity, thus diminishing Franklin’s opportunity for professional growth during
fieldwork. Furthermore, Principle 5G may also be relevant: “Occupational therapy personnel
shall be honest, fair, accurate, respectful, and timely in gathering and reporting fact-based
information regarding employee job performance and student performance” (p. 6). Don could
face conflicts of interest, as well as difficulty maintaining professional boundaries and
confidentiality and ensuring that his evaluation of Franklin is completely objective and unbiased.
ACCEPTING GIFTS FROM CLIENTS
Ray works as a pediatric occupational therapist in a county school system. He has developed
long-standing client relationships because the students have been on his caseload for many years.
As winter holidays were approaching, the parent of one of his students presented him with an
expensive watch. He felt uncomfortable accepting such a valuable gift, so he declined. The
parent wanted to show his appreciation for all of Ray’s hard work with his child. However, Ray
made the right decision.
Small tokens of appreciation, such as baked goods, candy, or cards, may be acceptable, but
accepting gifts of value could cause a conflict of interest. Principle 6C of the Code states that one
should “avoid conflicts of interest . . . in employment, volunteer roles, or research” (AOTA,
2015, p. 7). A professional must be unbiased and objective in treating clients, students, or
vendors. If he or she accepts something of value, others could perceive that the gift could
influence his or her treatment of the client, student, or vendor.
CONCLUSION
Occupational therapy practitioners and educators must understand the importance of maintaining
professional boundaries and conducting themselves appropriately. Whether one is working with
clients, engaging in research, or teaching a faculty member in academia, one must adhere to
professional boundaries to maintain an ethical practice. It is mandatory to abide by relevant state,
federal, and international laws as well as state practice acts, organizational policies, and other
applicable regulations. The AOTA Code as well as ethics documents from other professions can
provide guidance in the face of ethical dilemmas related to delineating acceptable professional
boundaries.
REFERENCES
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American Occupational Therapy Association. (2011). The American Occupational Therapy
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http://www. aota.org/-/media/Corporate/Files/Practice/Ethics/Advisory/Social-Networking.pdf
American Occupational Therapy Association. (2015). Occupational therapy code of ethics (2015).
American Journal of Occupational Therapy, 69(Suppl. 3), 6913410030. http://dx.doi.org/
10.5014/ajot.2015.696S03
American Psychological Association. (2010). Ethical principles of psychologists and code of
conduct: 2010 amendments. Retrieved from http://apa. org/ethics/code/index.aspx#
National Council of State Boards of Nursing. (2014). A nurse’s guide to professional boundaries.
Chicago: Author. Available at http://www.ncsbn. org/Professional Boundaries_complete.pdf
Tetreault, L. (2010). Professional boundaries: You are the professional. Retrieved from
http://www. nh.gov/nursing/documents/prof_bound.doc
Authors
Ann Moodey Ashe, MHS, OTR/L Practice Representative, Ethics Commission (2008–2011, 2011–
2014)
Loretta Jean Foster, MS, COTA/L OTA Representative, Ethics Commission (2008–2011, 2011–
2014)
This chapter was originally published at http:// www.aota.org/-/media/Corporate/Files/Practice/
Ethics/Advisory/professional-boundaries-adv.pdf. It has been revised to reflect updated AOTA
Official Documents and websites, AOTA style, and additional resources.
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